The basic biology of the virus, HIV, and the disease it causes, AIDS. The economic, social and political factors that determine who gets sick and who remains healthy, who lives and who dies. The progress of scientific research and medical treatments. The reasons for hope; the reasons for fear. (To get a glimpse of some of the materials that students have been posting on the course forums, go to @AIDSFAH or #AIDSFAH.)

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Richard Meisler, Ph.D.

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We are exploring the care provided to HIV positive patients. Today's session is a conversation with an infectious diseases doctor and her colleague who is a patient advocate. The physician is Dr. Patricia Brown, an infectious diseases specialist who works at the Detroit Receiving Hospital and is a professor at the Wayne State University Medical School. The patient advocate is Ms. Margareth Corkery. They work in the largest HIV practice in the state of Michigan. As you will see, they have a strong multidisciplinary team approach to caring for patients. Dr. Brown graduated from the University of California at Davis. And then from St. Louis University Medical School. Like many infectious diseases specialist, she has hospital wide responsibilities in addition to caring for her own patients. As one looks over Dr. Brown's professional history. One is struck by how many awards she has been given by students, interns, and residents, for teaching excellence. As you watch my conversation with her, you'll see why. Ms. Corcorie was born in Haiti. You'll remember the four H's, and Ms. Corcorie certainly remembers. The incorrect identification of Haitians as a risk group. After moving to Detroit, she earned a Master's degree in counseling at Wayne State University. When we were setting up, to record our conversation at the Detroit Receiving Hospital, I chatted with a number of people who worked in the HIV clinic with Dr. Brown and Ms. Korcari. I was moved by the impressions I came away with. Like Dr. Brown and Ms. Korcari, these people all cared deeply about their patients. They were concerned with their medical well-being, but also with their social and emotional health. Some of their patients meet with rejection in their families and communities. And these medical professionals were dedicated to providing the love and support that their patients might not get elsewhere. Here's part of our conversation in which we talk about what happens when an HIV patient first seeks care. Dr. Brown and Miss Corkerie are so warm and friendly that you'll see that I couldn't help but call them by their first names. Though you'll understand that no disrespect was intended. I'm talking with Dr. Patricia Brown and Ms. Margrethe Corkery, and we're in a very informal setting and without any disrespect I'm going to switch to Patty and Margrethe from the very beginning. We're here, at your HIV clinic in the medical center in Detroit, it's the largest HIV practice in the state. And perhaps we could begin by you telling us what happens when a patient comes in here for the first time? Perhaps recently diagnosed as HIV positive. What will happen to him or her when the person comes to this clinic? >> Well, they will meet with one of the patient advocates. And we make sure that this person has resour, is a, is aware of the resources that are available to them. We make sure that they have insurance. We also talk to them about what it means to them to be HIV-positive, especially if it's somebody who is newly diagnosed. So that we can refer them to mental health services, to support groups, so that they know they're not alone in this journey. >> Mm-hm. What resources do you them about? >> We tell them about KISS management agencies that can help them that can provide housing assistance, financial ins, assistance for their utilities. Also, we tell them about programs that are available to help them with their medication. Tell them about support groups. We also tell them about what we have going on in the clinics, for instance, we have a Pure Navigator program, which, which is comprised of our very own patients who come in to share their story with our other patients. And these old patients were doing very well with their managing their illness. And they're able to tell other patients, hey, I've been in your shoes, I know what you've gone through and I can tell you that it's really not as bad as you think it might be. So that gives the patients, the new patients, hope that okay I can, I can do better, I can beat this thing >> How long will that conversation last, usually? >> We try not to be in the way of the doctors because they do have a job to do. So, we're very flexible, and also we work with the patient. However long they want to talk to us. We let the doctors do their work and then we might go back to the room. Or tell them, hey, you want to talk, give us a call, here's my number, that type of thing. >> And so will they go from that conversation to the doctor's examining room or the doctor's office? >> No, in the exam, exam room. >> Uh-huh, uh-huh. And what does the doctor do? >> Okay, so, then we're going to start with the, sort of the medical evaluation. Then we're going to take a comprehensive history. It's still extremely important that we document in our records the individual's risk factor for infection. Because HIV is reportable, in the state of Michigan, and, the individuals who prepare the report will be looking at our documentation. So we can make sure we can continue to track and trend what the various risk groups are to help us understand how the epidemic has evolved, and unfolding, and where we need to target prevention efforts. So, a very comprehensive medical history, but really not that different from a comprehensive history that any patient when undergo when they present for primary care for the first time. then, physical exam, complete physical exam. The only exception would be for women if they need gynecologic exam, pap smear, we would generally schedule that for a separate visit. Because the time that we're alloted for the new patient visit often isn't going to be able to support that. But a complete physical exam. Again, nothing different than what you would have if you presented to a primary care doctor for the first time for a general health exam, and then a laboratory investigation. And really, that's a, a key part of the first visit, in that we need to understand where the person is at in terms of the infection. We screen them for past infection with Hepatitis A, B, and C to address do they need additional referrals for treatment? Do they need vaccination to protect them? Et cetera, et cetera. We screen them for sexually transmitted infections. That's extremely important to make sure that we're addressing those. And then we sort of pick up where the advocates have left off in terms of making sure that we're reenforcing the availability of services, getting on to insurance now, if they have, don't have it. The AIDS drug assistant program, if they don't have insurance are going to need coverage for medications. Although, we do have the advocates talk to them about prevention for positives, reducing the risk of transmission to others, safer sex. We, it's very important I think, that everyone reinforces those messages, so we counsel the patient about that and just address any concerns that they might have. We particularly need to make sure that we ensure that if they don't have a primary care provider for their other health needs. And they have other comorbidities, like diabetes or high blood pressure, that we get them hooked into primary care. And actually, this past year we started a primary care, practice here, where we have internal medicine specialists who come a certain day of the week and will see HIV-positive patients for primary care. Many times patients feel much more comfortable being seen here, than going yet to another office, a whole, another set of disclosures that they have to make. We have a kidney specialist who comes here one-half day a month, who will see patients who also have renal disease. And again, the same idea, they see the same front desk, the same medical assistance, the same but, a different doctor. So we just make sure that all of their other health care needs are being adequately addressed. So one-stop shopping really works in, in making it easier to pursue good healthcare? >> It's definitely ideal. It's, we haven't, I don't think we've achieved all of it yet. But we're, we're working towards that goal. And I think we do a very, very good job. Before we, go ahead Margorie. >> No, I was going to say, one other thing that we have in our clinic. We have a psychiatrist that comes here twice a week for half a day to see our patients. So that way, because we also, as patient advocate, we do a mental health assessment to, to make sure that if the person has some mental health issue, that they are connected with care. Because that would effect their retention to care, as well as adherence to medication. >> Mm-hm. >> So the estimates are up to a third of patients who have an HIV diagnosis have a major mental health diagnosis as well. And if you look at predictors of adherence to medication therapy. If you look at retention- >> Mm-hm. >> In care. Major mental health diagnosis that is not being adequately adjusted and treated is a major risk for not being able to be adherent to medications, and not being adherent to follow up visits. So you, for me as the HIV provider if we can't adequately address the mental health issues, and the same is true for substance abuse. Then we're never going to make progress trying to treat and manage the HIV. >> Well, those were my next two questions. Substance abusers and people who are suffering from mental health diagnoses. Tell use a little bit more about how you. Work with both of these groups of people, starting with the mental health folks. We know that, as you say, it, it's tremendous problem both a life problem and an HIV problem. How have you been working with that? >> Well, we do, do the mental health assessment. So that's the first thing where I start. And the, the tool that we use gives us an idea of what's going on with the person, because the person receives a score. So, what I usually do, I use that score to tell them, well it seems based on the answers you've given me that there's something going on. Can we talk about it? And I try to find out what their history is. And if they've never received mental health services, I try to, you know, talk to them about the reason why they might want to consider it, what the, the advantages would be if they were to do that. And if they have had a history, I try to find out what kept them from following up with the provider they were seeing before, and try to encourage them. >> Mm-hm. Let's say a person is deeply depressed. >> Mm-hm. >> As as I was waiting. to, to set up here I was talking with your nurse Jerry Burke. >> Mm-hm. >> And he telling me about a new patient who was deeply depressed, had not disclosed his diagnosis to, even to his family yet. What sort of help would a person like that get? >> Okay, well, we had a lot of these people. So first we have to make them understand, yes, it's an illness that's very serious because there's no cure for it. However, I try to give them what I call constructive hope. In the sense that I let them know, yes, it's not, it's nothing fun but there are people who have been living with this for so long. And if you meet with them, you talk to them, they can tell you how they handled the situation that they were in. And that can help them understand, okay, if I'm not by myself in this, then maybe, I can, I can fight it. Then I start with the person first. And then I try to work my way around about their support. Whatever support they have. We often, often time we offer them if you're not comfortable telling your partner about this diagnosis, bring them here. We'll do it together as a group. That way you're not alone in doing this. So we try to work wherever the person is at to see what will work best for them and give them different option. And they say, well, I want, I would like to do this and then we work with them. >> Mm-hm. >> So and then as the provider, you know, we, we keep the communication. We actually have a pre-clinic meeting before clinic gets off the ground. Where we go over the patient list with the advocate who works with us, and we talk about what's going on with each patient. And what our concerns are as the clinician, and then they'll tell us well they haven't had a mental health assessment. In a year or they had assessments six months and they had a high score, so then we'll make sure that we flag that individual. We want to make sure that they're reassessed or if they haven't been assessed in a year, we want to make sure that they're reassessed. And that, that she, one of our quality indicators in terms of the quality of care we're providing and last looked at. I mean, not only internally, we want to make sure we're providing high quality care, but it's looked at externally. By those who fund us and so when they come in and do their reviews of our practice. They'll be looking to see that there's documentation that there's an MHA or mental health assessment on a yearly basis that's documented on every patient. So we try to be anticipatory and, you know, identify these things up front. That being said we can talk about a patient and say, oh, she, you know, she's doing great. Everything's fine she'd say, and I walk in the room and say,. How are you doing? And that person bursts into tears and something, and so then I need to grab my, [LAUGH] because we're going to need to intervene. And if, if, the issue is, you know, loss, depression, something, you know, talking about the medications, or us really not going to be fruitful if we don't address, you know, the, the problem that's presenting itself most acutely. So we, we try to be proactive. Sometimes, we have to be reactive. Having a psychiatrist here and having the ability to get that, those services is something we had, we lost,. >> Mm-hm. >> because of funding problems and now, thankfully, we're going to have again. And I think we didn't realize until we lost it how absolutely key that was to, to keeping patients on track who, who do need ongoing mental health services. I'll say one other thing, people who practice infectious disease, adult infectious disease, had to train first as internists. There are varying levels of comfort with continuing to practice general internal medicine, depending on. Your own preferences, how long you've been out how much you have to keep up on. I think many of us feel comfortable with diagnosing depression and at least initiating antidepressant therapy, if it's necessary. >> Mm-hm. >> Pharmacologic therapy at least to get things started. And then perhaps we can hand over ongoing care to a mental health professional, or we work in concert with them. So we, we try our best to, to meet the patients' needs as quickly as possible. >> In a moment I'm going to ask you about the incredible teamwork that seems to characterize your practice. But I want to stick with talking about some of the patient subgroups that you have. >> Mm-hm. >> We've talked about the people who suffer from mental illness. Tell us about the substance abusers, and also what you've learned about how to help people who are addicted to various drugs. >> For me what I've learned is to just make them understand we don't judge here. We're just here to help you. So the best thing for you is to tell us exactly what's going on so that we understand, so we understand where exactly, how we can best help you. And I find that it helps a little, not to say that everybody comes and tells me their whole story, but at least they know, okay, I can be myself and. Say this is what I'm using. This is how often I've, this is when I've used. And then we can, and often times we want to refer them to treatment, but is, if they're ready for it. And they say they're not. I say, okay I understand, but know that this resource is available. All you have to do is give me a call, and we'll help you out. >> Mm-hm. >> And certainly active substance abuse, again, we need to try to address it. We need to try to refer them for treatment. But in and of itself does not present a contraindication to going ahead and getting on medication. So we would not not start antiretroviral therapy in someone from whom it was indicated just because of active substance abuse. And actually, it's been shown that heroin abusers can actually continue to use drugs and be quite adherent to therapy, and still at least gain the health benefits of, you know managing their HIV. >> Of not having AIDS. >> Yeah. >> Mm-hm. >> The crack use is a different problem. Crack use is associated with a much more chaotic and hectic lifestyle, and crack users, those who actively use aren't doing as well. we, we have available to us, a graphic that shows your viral load over time. And I can sit down with patients and show them. This was your viral load when you were using crack. And this was your viral load when you were in treatment. And this was your viral load. And sometimes seeing that pattern, the patient realizes impact that their, their active substance abuse has had on their health. The other issue with substance abuse I think is the risk for incarceration. As we know because you know of, of the legal ramifications. And again, recent literature has shown that incarceration among HIV positive individuals is a major risk factor for loss of virologic control. And so, we've worked, we work very well with Wayne County jail. We have a good relationship with healthcare providers there, who will call us if patients who identify our practices as their source of care, make sure that they continue their medications, stuff like that. I had a interesting experience just this summer, with one of our patience who had, was on probation. And realized that she had dropped 30, as they called it, on a urine, and because her substance abuse had relapsed, and anticipated that her, her next visit, she was going to perhaps being incarcerated. >> Last visit to her parole. >> To her parole officer, and so she said I'm going to bring my list of medications with me. She asked me to print out an extra list and I thought that's great coping and, you know, it was remarkable. I'd never really thought of it before, but she was prepared. >> Do you think she was going to get those medications when she was incarcerated? >> Yeah, actually, they've, as I've said, they've, done I think a very good job of ensuring that patients. Patients who get that continuity care, including during periods of prolonged incarceration can arrange to have a patient come here for visits. >> Do you? >> Oh yeah. They can come, absolutely. Absolutely.